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KPAC & KCSD Facility Use Form
* Required form for consideration of Knoxville Community School District facility use.
* Liability insurance is required to rent school facility - Requirements: MINIMUM $1 million liability as well as KCSD listed as an additional insured.
* Please allow at least two business days for a response to all facility use requests.
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Checklist prior to completing this form:
1. Read Board Policies 908 and 909 (link provided below) prior to submitting this form.  
2. Read all questions of this request form before entering your answers.
3. Please gather a roster (expected attendees - adults and/or youth) to be emailed after the submission of this form.
I agree to using KCSD facilities as outlined in Board Policy 908* (Community Use of School District Buildings, Sites and Equipment).  *Facility rules, regulations and fees are listed in this policy for your convenience. *
Required
I agree to using KCSD facilities as outlined in Board Policy 909* (Use of School District Facilities Regulation).  *Facility rules, regulations and fees are listed in this policy for your convenience. *
Required
Organization or Group Name *
Contact Information: Name/Email/Phone *
Billing Contact Information: Name/Address/Phone
Is your organization affiliated with Knoxville Schools? *
Many activities/sports exist that encourage KCSD and other area youth to be involved with the goal/hope of encouraging them to participate in District-Sponsored Organizations in the future, but these organizations are not tied to the District in any other way. (Note: Knoxville School activities and events take priority in all facilities.)
Required
Place of Meeting/Event *
Check any preferred location.
Required
Purpose of Meeting/Event *
(Type of Activity, Event or Sport)
Roster *
Please list your roster (including all adults & children involved)
Date(s) Needed *
Please note: The form allows for multiple dates with the SAME start and end TIMES.  If you have varying start times, use separate (additional) forms.  Examples:  Practice 7:00 pm on 5 consecutive Mondays --- One Form.  Practice 5:00 pm on 2 Mondays and 3:00 on Tuesdays --- Two Forms
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Additional Date (2)
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Additional Date (3)
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Additional Date (4)
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Additional Date (5)
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If more than five dates are needed please list here.  (mm/dd/yy format)
Start Time (When the building needs to be ready including prep time) *
Time
:
End Time *
Time
:
Please provide any additional information that may be helpful in scheduling a facility for your organization. Is there anything else we should know?
(additional event details)
Will you be serving food?  **Note: Food is prohibited at KPAC. This includes rehearsals and performances. Those renting the facility are reminded that you are responsible for assisting with this policy. A reminder to your audience is appreciated. *
Required
If you are serving food, please describe.
Will you require any special equipment? *
Required
If you are requiring any special equipment, please describe.
Chairs (#), Tables (#), Sound system, Projection system, Specify stage equipment, Podium, Food Service Equipment
Do you have any questions? Other details? Please note here.
(additional event details)
Damages connected with the use of KCSD facilities and/or equipment will be paid for by the person renting the facility. Tape/adhesives/glitter are not permitted on the walls, windows, or seats in the KPAC. *
Required
**IMPORTANT: *
Please email your certificate of insurance - specific policy needs: minimum liability limit of $1 million and Knoxville Community School District listed as an additional insured -  to: ryan.paulsen@kcsd.k12.ia.us 
For Office Use Only
Rental Charge:

Other Charges:

Reasons for Other Charges:

Custodians Assigned:

Cooks Assigned:

Complaints, Damages, Problems Reported:

Date Fees Paid:


For Custodian Use Only
Actual time the building was used by the Groups or Individual ________ to ________ Total Time ________

Total Time Worked at the Event ________ including preparation and cleanup.
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